Transcondylar distal humerus fractures
are usually high energy comminuted difficult fractures, technically difficult
to manage. Anatomic reduction, rigid fixation and early motion are desirable,
if technically possible. There are a variety of techniques for fixation.
Here, Herbert screws were used to secure the two central purely osteochondral
fracture fragments to each other and to the proximal humerus.

Click on each image
for a larger picture

81 year old physically active woman
sustained a left elbow fracture in a syncope related fall.

Lateral and central fracture component
displacement.

Unusual contour visible at the medial
metaphyseal flare.

This is seen on the lateral view to
be the anterior half of the central articular surface.

This is the fracture pattern: lateral
and central column - Anterior view:

The central column is additionally
split into an anterior (blue) and posterior (green) fracture fragments.

View from below.

Lateral view.

Open reduction via olecranon osteotomy.
The ulnar nerve is retracted with a penrose drain. The articular
surface was reconstructed, then secured to the shaft. After recovering
the rotated anterior articular fragment, the anterior and posterior halves
of the central articular component were secured with .062" pins. These
pins were replaced one at a time with Herbert screws.

Later in the case, the small medial
osteochondral fragment was secured with absorbable sutures (not shown).

In similar steps, the reconstructed
central articular component was secured to the proximal humerus with pins.
Once satisfactory reduction was obtained (not yet, as seen here...), the
pins were replaced by more Herbert screws. This allowed fixation of the
purely osteochondral segments without prominent harware.

Screws were secured from the central
articular component to the more proximal humeral cortices.

These provided biplanar fixation, eventually
with two screws in each direction.

The lateral column was then secured
with two cannulated screws.

The olecranon osteotomy was closed
with a 6.5 mm lag screw and (belt and suspenders) tension band technique.

Anatomic reduction.

She began immediate protected motion
and discontinued splint use at two weeks, despite recommendations to the
contrary. These films are two months postop: